NCLEX Review Guide: Newborn Initial Physical Examination

Timing and Purpose

• The initial newborn physical examination should be performed within 24 hours of birth to identify any congenital abnormalities, birth injuries, or conditions requiring immediate intervention. This comprehensive assessment establishes baseline data for future comparisons and helps detect any deviations that may require further evaluation.
• A second complete examination is typically performed before discharge from the birthing facility to ensure stability and identify any issues that may have developed since birth.

Components of the Initial Assessment

• The initial assessment includes both the Apgar score (performed at 1 and 5 minutes after birth) and a comprehensive head-to-toe physical examination. The Apgar evaluates five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
• The comprehensive physical examination assesses all body systems, vital signs, anthropometric measurements, and gestational age assessment using tools such as the Ballard Score or Dubowitz criteria.

Vital Signs

• Temperature: Normal axillary temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hypothermia (below 36.5°C) can lead to increased oxygen consumption, metabolic acidosis, and hypoglycemia, while hyperthermia (above 37.5°C) may indicate infection or dehydration.
• Heart Rate: Normal newborn heart rate ranges from 120-160 beats per minute. The rate may increase with crying or activity and decrease during sleep. Persistent tachycardia (>160 bpm) may indicate infection, anemia, or cardiac issues, while bradycardia (<100 bpm) requires immediate attention.
• Respiratory Rate: Normal newborn respiratory rate is 40-60 breaths per minute. Respirations should be assessed for at least one full minute and should be regular and unlabored. Tachypnea (>60 breaths/minute), retractions, nasal flaring, or grunting may indicate respiratory distress.
• Blood Pressure: Blood pressure is not routinely measured in healthy newborns but may be assessed in specific situations. Normal systolic BP ranges from 60-90 mmHg, while diastolic ranges from 30-60 mmHg.

Anthropometric Measurements

• Weight: Average term newborn weight is 3000-4000 grams (6.6-8.8 pounds). Weight is classified as appropriate for gestational age (AGA), small for gestational age (SGA, <10th percentile), or large for gestational age (LGA, >90th percentile). Birth weight should be plotted on standardized growth charts.
• Length: Average term newborn length is 48-53 cm (19-21 inches). Length is measured from the crown of the head to the heel with the newborn fully extended.
• Head Circumference: Average term newborn head circumference is 33-35 cm (13-14 inches). Head circumference is measured around the largest part of the head, from the occiput to the forehead.
• Chest Circumference: Average term newborn chest circumference is 30-33 cm (12-13 inches), typically 2-3 cm less than head circumference. It is measured at the level of the nipples.

Head and Neck

• Head: Assess shape, symmetry, and presence of molding (temporary elongation of head due to pressure during vaginal delivery) or caput succedaneum (edema of the scalp that crosses suture lines). Check fontanelles: anterior fontanelle (diamond-shaped, 2-3 cm) and posterior fontanelle (triangular, 0.5-1 cm). Fontanelles should be soft and flat.
• Face: Assess symmetry at rest and during crying. Check for facial paralysis, which may indicate birth trauma. Observe for dysmorphic features that might suggest genetic disorders.
• Eyes: Assess for size, symmetry, placement, and presence of edema. Check for subconjunctival hemorrhages (common and benign) and red reflex (absence may indicate cataracts or other abnormalities). Note that newborns can see light and dark and focus at a distance of 8-12 inches.
• Ears: Assess placement, shape, and alignment. The top of the ear should align with the outer canthus of the eye. Low-set ears may indicate chromosomal abnormalities.
• Nose: Assess patency by occluding one nostril at a time. Newborns are obligatory nose breathers, so nasal obstruction can cause respiratory distress.
• Mouth: Assess lips, palate, and tongue. Check for cleft lip/palate, Epstein's pearls (small white cysts on gums or palate), and tongue-tie (ankyloglossia). Evaluate sucking reflex by inserting a gloved finger.
• Neck: Assess for range of motion, masses, and excessive skin folds. Check for torticollis (limited range of motion due to sternocleidomastoid muscle injury) and thyroid enlargement.

Chest and Respiratory System

• Chest: Assess shape, symmetry, and movement. The chest should be cylindrical with symmetric expansion. Note any retractions, which may indicate respiratory distress.
• Breasts: Assess for size and symmetry. Breast enlargement and even secretion of "witch's milk" may be present due to maternal hormones and is normal.
• Lungs: Auscultate all lung fields for breath sounds, which should be clear and equal bilaterally. Note any adventitious sounds such as crackles, wheezes, or grunting.
• Work of Breathing: Assess for signs of respiratory distress, including tachypnea, nasal flaring, grunting, retractions (suprasternal, intercostal, or subcostal), and seesaw respirations (paradoxical breathing).

Cardiovascular System

• Heart: Auscultate apical pulse for one full minute. The PMI (point of maximal impulse) is typically at the 4th intercostal space, left of midclavicular line. Assess rate, rhythm, and presence of murmurs.
• Pulses: Assess brachial, femoral, and pedal pulses. Femoral pulses should be equal bilaterally; weak or absent femoral pulses may indicate coarctation of the aorta.
• Perfusion: Assess capillary refill time (should be <3 seconds), skin color, and temperature. Cyanosis of extremities (acrocyanosis) is common and normal in the first 24-48 hours.

Abdomen

• Inspection: Assess contour (slightly rounded), umbilical cord (should have 3 vessels - 2 arteries and 1 vein), and presence of any abnormalities such as omphalocele or gastroschisis.
• Auscultation: Listen for bowel sounds in all four quadrants. Bowel sounds should be present within the first hours after birth.
• Palpation: Gently palpate for masses or organomegaly. The liver edge may be palpable 1-2 cm below the right costal margin. The kidneys may be palpable in thin newborns.
• Umbilical Cord: Assess for signs of infection (redness, drainage, odor) and proper drying/separation. Check for the presence of two arteries and one vein, as a single umbilical artery may be associated with congenital anomalies.

Genitourinary System

• Male Genitalia: Assess penis size, position of urethral meatus (to rule out hypospadias or epispadias), and scrotum (for size, symmetry, and presence of testes). Testes should be descended bilaterally; undescended testes (cryptorchidism) is common in preterm infants.
• Female Genitalia: Assess labia and clitoris. Whitish discharge or pseudomenstruation (slight vaginal bleeding) may be present due to maternal hormones and is normal.
• Urination: Document first void, which should occur within 24 hours of birth. Absence of urination may indicate urinary tract abnormalities.

Anus and Rectum

• Assess for anal patency and position. Document first stool (meconium), which should pass within 24-48 hours after birth. Delayed passage may indicate intestinal obstruction or Hirschsprung's disease.

Musculoskeletal System

• Extremities: Assess all extremities for movement, symmetry, and deformities. Count fingers and toes.
• Spine: Examine entire length for straightness, integrity, and presence of abnormalities such as spina bifida or sacral dimples/tufts of hair that may indicate underlying spinal defects.
• Hips: Assess for developmental dysplasia of the hip (DDH) using Ortolani and Barlow maneuvers. A "clunk" feeling or sound during these tests may indicate hip instability.
• Clavicles: Palpate for fractures, which are common birth injuries. Signs include crepitus, asymmetric Moro reflex, or decreased movement of the affected arm.

Neurological System

• Posture: Term newborns typically maintain a flexed position due to intrauterine positioning. Assess for symmetry of movement and tone.
• Tone: Assess for hypotonia (decreased tone) or hypertonia (increased tone). Normal newborns have good tone with resistance to passive movement.
• Primitive Reflexes: Assess for presence and symmetry of primitive reflexes, including:
  • Moro reflex: Symmetrical extension and abduction of extremities followed by flexion and adduction in response to sudden stimulus
  • Rooting reflex: Turning head toward stimulus when cheek or corner of mouth is touched
  • Sucking reflex: Rhythmic sucking when stimulus is placed in mouth
  • Palmar grasp: Flexion of fingers when palm is stimulated
  • Plantar grasp: Flexion of toes when sole is stimulated
  • Stepping/walking reflex: Alternating stepping movements when held upright with feet touching surface
  • Babinski reflex: Fanning of toes with dorsiflexion of big toe when sole is stroked (normal in newborns)

Skin

• Color: Assess overall color and presence of jaundice, cyanosis, pallor, or plethora. Normal newborn skin is pink with acrocyanosis common in first 24-48 hours.
• Common Variations: Note normal variations such as:
  • Milia: Small white papules on nose, chin, and forehead due to blocked sebaceous glands
  • Erythema toxicum: Benign rash with erythematous macules and papules that appears within first few days
  • Mongolian spots: Blue-gray pigmentation commonly on sacral area and buttocks, more common in darker-skinned newborns
  • Nevus simplex (salmon patch): Pink macules on eyelids, forehead, or nape of neck
  • Nevus flammeus (port-wine stain): Dark red macules that do not blanch
  • Vernix caseosa: White, cheese-like substance that protects skin in utero
  • Lanugo: Fine, downy hair, especially on shoulders and back, more prominent in preterm infants
• Turgor: Assess skin turgor by pinching skin on abdomen; it should return quickly to normal position. Poor turgor may indicate dehydration.

Ballard Score

• The New Ballard Score (NBS) assesses neuromuscular and physical maturity to determine gestational age. The neuromuscular assessment includes posture, square window, arm recoil, popliteal angle, scarf sign, and heel-to-ear maneuver. The physical maturity assessment includes skin, lanugo, plantar surface, breast bud, eye/ear, and genitalia.
• Scores range from -10 to +50, corresponding to gestational ages from 20 to 44 weeks. This assessment helps classify the newborn as preterm (<37 weeks), term (37-42 weeks), or post-term (>42 weeks).

Classification by Weight and Gestational Age

• Newborns are classified based on the relationship between birth weight and gestational age:
  • Appropriate for Gestational Age (AGA): Birth weight between 10th and 90th percentile for gestational age
  • Small for Gestational Age (SGA): Birth weight below 10th percentile for gestational age
  • Large for Gestational Age (LGA): Birth weight above 90th percentile for gestational age
• This classification helps identify newborns at risk for specific complications. For example, SGA infants are at higher risk for hypoglycemia, hypothermia, and polycythemia, while LGA infants are at higher risk for birth trauma, hypoglycemia, and respiratory distress.

Differentiating Common Newborn Findings

Memory Aids for Newborn Assessment

Procedure: Performing a Systematic Newborn Assessment

1. Prepare the environment: Ensure warm room temperature (24-25°C), good lighting, and all necessary equipment.
2. Wash hands thoroughly and don gloves if necessary.
3. Begin with observation: Observe the newborn's color, posture, activity level, and respiratory effort before disturbing them.
4. Measure vital signs: Temperature, heart rate, and respiratory rate.
5. Obtain anthropometric measurements: Weight, length, and head circumference.
6. Perform systematic head-to-toe assessment:
   • Head and face: Fontanelles, sutures, facial symmetry, eyes, ears, nose, mouth
   • Neck: Range of motion, masses
   • Chest: Shape, symmetry, breath sounds, heart sounds
   • Abdomen: Contour, umbilical cord, bowel sounds, palpation
   • Genitalia and anus: Structure, patency
   • Extremities: Symmetry, movement, digits, hip stability
   • Back: Spine, sacral area
   • Skin: Color, texture, lesions, birthmarks
7. Assess primitive reflexes: Moro, rooting, sucking, palmar grasp, etc.
8. Assess gestational age using Ballard Score or similar tool.
9. Document all findings thoroughly, noting normal findings and any variations or abnormalities.
10. Communicate significant findings to the healthcare team and parents.

Common Pitfalls in Newborn Assessment

• Mistaking normal variants for abnormalities: Many findings that appear concerning (molding, caput succedaneum, Mongolian spots, erythema toxicum) are normal variants. Thorough knowledge of normal newborn characteristics prevents unnecessary concern.
• Incomplete assessment: Rushing through the assessment or failing to assess all systems thoroughly may result in missed findings. Always follow a systematic approach.
• Improper technique: Incorrect measurement techniques can lead to inaccurate data. For example, measuring length without fully extending the newborn or measuring head circumference incorrectly.
• Poor timing: Assessing the newborn during periods of distress or crying may yield inaccurate findings, particularly for vital signs and reflexes. When possible, assess during a quiet alert state.
• Inadequate documentation: Failing to document findings comprehensively or using vague terminology can lead to communication errors and poor continuity of care.